Healthcare Provider Details

I. General information

NPI: 1598885980
Provider Name (Legal Business Name): AHSAN ALAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 WASHINGTON ST TUFTS-NEMC BOX#391
BOSTON MA
02111-1526
US

IV. Provider business mailing address

28 BRAINARD AVE APT 104
MEDFORD MA
02155-5125
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-1573
  • Fax: 617-636-2369
Mailing address:
  • Phone: 617-314-9514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number229462
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: